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This review summarizes the evidence base for using compression, massage, caloric replacement, cold, and heat as exercise recovery aids in sport.

1University of Iowa Carver College of Medicine, Iowa, IA; 2Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa, IA; 3Institute for Orthopaedics, Sports Medicine, and Rehabilitation, University of Iowa, Iowa City, Iowa; 4Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa, IA; 5Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa, IA; 6Department of Health and Human Physiology, University of Iowa, Iowa, IA; and 7Department of Orthopaedics and Rehabilitation, University of Iowa Carver College of Medicine, Iowa, IA

Introduction

Athletes commonly employ recovery aids to help cope with the demands of frequent bouts of physical training, minimize exercise-induced muscle soreness, and help maximize the benefits of their training sessions. Many commercial products claim to provide such benefits, although the evidence behind these claims is often quite minimal, and the available evidence commonly carries significant financial conflicts of interest. This review aims to summarize the evidence base for five of the most common recovery aids: compression, massage, caloric replacement, cold, and heat. Level of evidence for or against the use of these methods can be found in the Table. An explanation of the Oxford Centre for Evidence-Based Medicine Level of Evidence Grading Scale can be found on its Web site (73).

Compression

The theoretic benefits of compression in the athletic setting include decreasing the potential space available for swelling by creating an external pressure gradient and thus reducing the secondary inflammatory response following exercise, enhancing blood flow, aiding in removal of waste products, increased limb oxygenation, and reduction of recovery heart rate (3,25,28,44,45,84).

There is mixed evidence on the effectiveness of compression garments as a recovery aid in sport. This may be due to differences in study populations, type of compression garment (intermittent pneumatic vs static), duration of treatment, and type of exercise performed (44,45,61).

Beliard et al. (8) reviewed 24 original articles on lower limb compression garments. They concluded that wearing compression garments on the lower limbs during endurance or resistance exercise did not show benefit in immediate performance, performance recovery, or delayed-onset muscle soreness (DOMS). However, when worn during recovery, there was a trend toward improvement in performance recovery and a decrease in DOMS in both endurance and resistance exercise. There was no relationship between the duration of treatment, type of pressure (low degressive, high degressive, or low progressive), or level of pressure applied and the effect on performance recovery or DOMS.

In addition to the studies reviewed by Beliard et al. (8), there are two additional well-done studies on the effects of compression garments and sport performance. Neither identified a benefit of wearing compression garments during athletic tasks. A study of 11 National Collegiate Athletic Association (NCAA) division I baseball pitchers and 10 NCAA division I golfers wearing upper body compression garments found no difference in power activities (fastball pitch velocity or golf driving distance) but did note an improvement in accuracy (fastball in baseball and drive, approach shot, and chipping in golf) thought to be related to improvements in proprioceptive cues (47). A study on 11 male 400-m runners utilizing lower limb compression garments found no difference in athletic performance (400-m time and 100-m split times) but did find lower rates of perceived exertion when wearing the garments and a trend toward increased rate of lactate clearance (32).

However, other studies have demonstrated that compression garments are beneficial for recovering from athletic tasks. A recent meta-analysis by Hill et al. (44) found benefits of compression garments on DOMS, muscular strength, muscular power, and circulating creatine kinase levels. The effect size was moderate for each of these outcome measures. A 2013 systemic review concluded that “there are beneficial effects of compression clothing, especially during intermittent high-intensity exercise such as repeated sprinting and jumping rather than during submaximal endurance exercise” (15).

A study on 24 diverse athletes at the U.S. Olympic Training Center found that peristaltic pulse dynamic compression was effective in reducing short-term muscle tenderness as measured by pressure-to-pain threshold (84). Compression also has been shown to have beneficial effects on self-reported DOMS (3,29,37,41,44,79).

Despite improvement in self-reported DOMS, no improvements in performance on intermittent sprint or explosive power performance tasks were found in a cohort of rugby players (29). Similarly, in a study of eight highly trained field hockey players, no physical markers of recovery were improved by wearing compression stockings for 24 h after exercise despite subjective improvements in muscle soreness (79).

A study on repeated 40-km cycling time trial performance found decreased time on the subsequent time trial when lower extremity compression garments were worn for 24 h between trials as compared with a placebo garment (28). Improvement in sprint and endurance performance was noted in a crossover study on 22 rugby athletes (41). One study of static below-the-knee compression stockings in a cohort of marathon runners found improvement in run to exhaustion time 2 wk following the marathon when used for 48 h after the event (3). A small study observed faster improvement in muscular strength following strenuous resistance exercise (37).

Overall, the literature supports the view that compression garments are beneficial as a recovery aid. They decrease DOMS and improve performance on distance running, cycling power, muscular strength, and muscular power and attenuate circulating levels of markers of muscle injury. While the effect sizes in most studies are quite small, the pooled effects described in the recent meta-analysis and systemic review describe consistent and meaningful differences for the athlete.

There are few potential risks of compression garments. The costs of sequential compression devices may not be justified since similar improvements in DOMS and performance seem to be seen with much less expensive compression garments.

Massage

Massage has a long history as a recovery modality among many types of athletes. It is likely the most commonly used recovery aid across all sports and levels of competition. However, despite its ubiquity, there is remarkably little evidence for its effectiveness. Studies of massage are commonly limited by small size and wide variability in technique, duration, intensity, and timing. Most studies of massage as a recovery aid involve one massage session after an exercise event. There is wide variability in the timing and duration of the massage intervention, and outcome measures are likewise quite diverse. It is also difficult to study the effectiveness of massage due to the lack of a meaningful sham control (11). These challenges conspire to make it very difficult to pool available data for meta-analyses.

Despite these challenges, there are multiple small case series, randomized controlled trials, and systematic reviews in the literature (11). One recent meta-analysis reviewed the available literature but discarded nearly all of the identified studies due to poor quality or other limitations (92). It did, however, support the effect of massage on delaying the time to DOMS, which may be important to some athletes under certain conditions. DOMS was significantly decreased at the 24-h time point but not at 48 or 72 h. Interestingly, the same meta-analysis demonstrated a reduction in muscular strength 1 h after massage but not at the 24-, 48-, or 72-h time points. This creates an interesting conundrum for the athlete, coach, or team medical personnel; sports massage for 20 to 30 min within 2 h of physical exertion does seem to be effective in delaying DOMS. However, the same intervention seems to cause a short-term decrease in muscular strength. For certain athletes, under certain conditions, this trade-off may be worthwhile. However, it is unlikely that most athletes would accept such a trade-off if they were aware of the evidence. Currently, there is no evidence that massage enhances recovery from any type of exercise or improves performance during subsequent bouts of exercise (5,69).

Some researchers have focused on studying surrogate measures of effectiveness. The notion that massage might be beneficial for clearing waste and by-products of exercise has been a particularly attractive target. However, studies on the effects of massage on blood lactate levels and blood flow have offered no clear relationship between massage and any marker of muscular blood flow or lactate clearance (17,26). Massage may have an effect on the immune response to exercise, especially in modulating circulating levels of IgA (90). Creatine kinase and markers of inflammation were reduced following massage in one study (26). It is difficult to determine whether such biochemical changes are due to the mechanical effect of the massage or are from potential psychological stress-reducing effects.

There may be some psychological and/or neuroendocrine benefit of massage, even if it does not directly contribute to physical recovery. One recent randomized controlled trial demonstrated decreased heart rate variability and diastolic blood pressure recovery when massage was used to aid in recovery after exhaustive bouts of exercise (4). Subjective measures of muscle soreness and pain seem to improve after even brief massage interventions (5,53,70). No study has demonstrated any improvement or delay in DOMS based on more objective evaluations, such as pressure-pain measurement.

While manual massage is by far the most commonly studied modality, there are several devices on the market that are meant to simulate massage or recreate the purported benefits of massage. Among the most common nonmanual massage techniques is the use of a foam roller to provide controlled pressure to muscles. One recent randomized controlled trial of foam rolling found the intervention to be effective for decreasing DOMS, with a large improvement in pressure-pain threshold 24 and 48 h after a treatment. The study also found small but significant improvements in several performance-related tasks. Specifically, subjects had improved 30-m sprint time 72 h after massage, broad-jump distance 48 and 72 h after massage, change-of-direction speed (a measure of agility) 48 and 72 h after massage, and number of squat repetitions (a measure of muscular endurance) 48 h after massage (71).

In addition to the studies on massage in human subjects, there is one well-done dose-effect study of simulated massage in a rabbit model. Haas et al. (39) instrumented the hind lower extremities of 24 rabbits with a nerve stimulator. They simulated a hard eccentric muscle challenge and then treated the muscles with mechanical simulated massage. They used a 2 × 2 × 2 dose allocation of low and high duration, intensity, and frequency. The primary outcome measure was peak muscle torque on subsequent muscle stimulation. All animals had a decrease in their maximal muscle torque following the simulated eccentric exercise, but rabbits that had been treated with faster (more frequent pressure) massage and higher amplitude massage pressure showed attenuated decrease in muscle torque. There was no effect from the duration of simulated massage.

In summary, massage may delay the time to DOMS but may also decrease muscular strength for a brief period following the treatment. Subjective measures of DOMS are markedly improved after even low-dose massage treatments. Some of this improvement may be due to the psychological or neuroendocrine effects of massage. Massage does cause small improvements in circulating immunoglobulins, creatine kinase, and markers of inflammation. However, it seems to have no effect on circulating lactate. Foam rolling may decrease DOMS and improve athletic performance.

There are case reports of injuries from sport-related massage, most notably, brachial plexus injuries (23) and vertebral pedicle fractures (38). Most authors note rashes and skin sensitivity as contraindications to sport massage. However, there is no evidence that massage worsens such conditions (11).

Calorie Replacement

Calorie replacement after exercise is necessary for repletion of muscle glycogen and stimulation of muscle protein synthesis for repair and growth. The importance of timing and nutrient composition largely depends on the duration and intensity of the exercise and timing of subsequent effort (1). For athletes training or competing no more frequently than every 24 h, muscle glycogen stores will typically be replenished by simply including sufficient carbohydrates in the athlete’s diet (1,7,19,55). However, when the athlete’s demands include multiple training efforts or competitions within a single day or on successive days (such as bicycle stage racing), more rapid repletion of glycogen stores appears beneficial (21,22,55,66,87). Ivy et al. (52) reported increased rates of muscle glycogen storage when carbohydrates was replaced immediately after exercise compared with delaying replacement by 2 h, and there is extensive evidence that eating foods with higher glycemic index increases the rate of glycogen synthesis after exercise (20–22). The American College of Sports Medicine Position Statement on Nutrition and Athletic Performance recommends carbohydrate replacement within 30 min of exercise with 1.0 to 1.5 g carbohydrate·kg−1 at 2-h intervals up to 6 h (1).

Protein supplements are commonly used by athletes to enhance recovery of muscle function and/or attenuate the muscle-damaging effects of exercise (31). However, a recent systematic review by Pasiakos et al. (71) concluded that although there is overwhelming evidence that protein supplementation increases after exercise muscle anabolism, there are no well-done studies that have demonstrated any decrease in muscle damage or recovery of muscle function after exercise.

Postexercise ingestion of protein in combination with carbohydrate gained popularity based on early studies suggesting increased rates of muscle glycogen repletion when protein was added to carbohydrate (102). Berardi et al. (10) confirmed increased rates of muscle glycogen resynthesis with a carbohydrate-protein supplement compared with those with carbohydrate alone; however, they failed to demonstrate improvements in performance measures. Other studies have demonstrated improvements in performance associated with the addition of protein, but several have been criticized methodologically for failing to supply an isocaloric carbohydrate-only beverage or not standardizing glycogen depletion protocols (9,33,57,60,63,85,91,96). Several other studies evaluating isocaloric carbohydrate versus carbohydrate-plus-protein supplementation have failed to demonstrate any ergogenic benefit of the addition of protein (10,12,13,67,77,80–83). Protein may offer benefits beyond its effect of muscle glycogen. There is limited quality evidence that protein-carbohydrate replacement may increase rates of protein synthesis and decrease protein degradation following endurance exercise (33,60,63).

While multiple commercial products are available and marketed to optimize recovery, several recent studies have evaluated readily available whole foods. Kammer et al. (56) demonstrated that the recovery benefits of cereal and nonfat milk were at least equivalent to a carbohydrate-electrolyte sports drink. Recent studies have also demonstrated that chocolate milk is a viable option for restoring muscle glycogen and promoting protein synthesis following exercise (57,60,75,77,78,91).

In summary, no particular calorie replacement study is more beneficial than eating a normal healthy diet when bouts of exercise are at least 24 h apart. However, for athletes training or competing more frequently than every 24 h, using earlier carbohydrate replacement and eating foods with higher glycemic index do improve muscle glycogen replenishment. Protein supplementation and protein-carbohydrate recovery aids improve markers of muscle recovery, but these have not been shown to improve recovery of muscle function after exercise or attenuate the muscle injury that occurs during exercise. Eating whole foods seems to be as beneficial as consuming specially engineered recovery foods or beverages.

Interestingly, we were unable to identify any studies that demonstrated any impaired performance, decreased glycogen repletion, or decreased skeletal muscle protein synthesis with increased caloric intake. In every circumstance, consuming more calories seems to have been beneficial for every marker of recovery. However, overconsumption of calories following exercise can lead to unwanted weight gain and/or gastrointestinal (GI) distress. However, if recovering from a bout of exercise is the athlete’s goal, consuming more calories seems to be beneficial. Other than weight gain and GI distress, the only other potential detriments of eating calorie replacement products seem to be related to cost and nutritional substitution. Many of the commercial calorie replacement products are quite expensive and are not any better than whole foods. Additionally, they are typically dense in macronutrients but poor in micronutrients. Athletes may inadvertently substitute calorie replacement products for more nutritious whole foods.

Cold

Most of the literature on cold therapy as a recovery modality involves cold water immersion. Although it is frequently used to treat muscle and tendon soreness, ice massage has not been shown to be an effective recovery aide (48,49,51,100). Cold is postulated to work by affecting inflammation, blood flow, nutrient transport, nerve conduction velocity, and pain perception (2,14,43,95).

A 2012 Cochrane review revealed low-quality evidence supporting cold water immersion as an effective therapy for decreasing DOMS compared with rest following vigorous exercise (14). Cold water immersion groups (temperatures ranged from 10°C to 15°C in 13 of 17 studies; four were 5°C to 9°C) had less DOMS at 24, 48, 72, and 96 h after exercise (14). A recent meta-analytical review by Poppendieck et al. (74) involving 21 studies and 216 subjects concluded that cold water immersion is a useful recovery aide. The greatest improvements in recovery and performance in their review were noted in studies that used full body cold water immersion as opposed to partial body cooling (74).

In a study on 24 American football players, Elias et al. (30) compared a single 14-min cold water immersion session with passive rest and contrast water therapy. In this study, cold water immersion was found to be superior in reducing muscle soreness, improving physical performance in jump and sprint activities, and reducing perceived fatigue at 24 and 48 h (30).

A recent systematic review by Halson (40) supports cold water immersion as an effective recovery aide for weight training, running, and eccentric exercise but did not find such benefit for cycling or swimming. Halson (40) found cold water immersion to have detrimental effects on subsequent sprint performance if utilized between bouts of exercise that occur 30 to 60 min apart based on studies by Schniepp et al. (86) and Crowe et al. (27). However, Yeargin et al. (101) noted markedly improved 2-mile run times in athletes who underwent cold water immersion (14°C for 12 min) following a 90-min run in hot temperatures. This suggests that cold water immersion may be beneficial for recovery from exercise in hot temperatures, even when the time between exercise bouts is short. This effect was likely due to maintaining a lower core body temperature during the cold water immersion trials.

The temperature of the water for cold or cool water immersion has not been systematically evaluated. Halson’s (40) review suggests that optimal cold water immersion involves full body submersion in 10°C to 15°C water for 14 to 15 min. Poppendieck et al. (74) also support that a water temperature of 12°C to 15°C is optimal. Shorter immersion times have not shown the same benefit (72).

A new type of cold treatment has emerged over the past several years. Whole body cryotherapy (WBC) consists of whole body exposure to air temperatures of −110°C to 140°C for 2 to 3 min either before or after exercise (6). Wozniak et al. (99) in 2007 demonstrated that a single WBC session in −120°C to 140°C for 3 min preceding exercise bouts in kayakers demonstrated mild improvements in biomarkers of lysosomal activity after 6 d of use. Wozniak et al. (98) also published in 2007 that three WBC sessions used prior to training demonstrated reduced biomarkers of antioxidant enzymes (superoxide dismutase, glutathione peroxidase) compared with training without WBC. From these studies, it appears that WBC use prior to exercise decreases levels of both antioxidative enzymes and lipid peroxidation products and may attenuate reactive oxygen species production and decrease muscle injury during exercise (98,99).

In 2009, Mila-Kierzenkowska et al. (65) reported similar results in female kayakers, supporting the idea that WBC use reduces oxidative stress from exercise. In 2013, Wozniak et al. (97) supported their earlier results by again demonstrating decreased biomarkers of oxidative stress in elite rowers following preexercise treatment with WBC. They did not find a change in creatine kinase levels with WBC. Mila-Kierzenkowska et al. (64) in 2013 demonstrated similar results with decreased biomarkers of oxidative stress in elite volleyball players when using preexercise treatment of WBC. In 2014, Sutkowy et al. (88) reproduced results of earlier studies. They showed that a preexercise WBC session in the morning and a second postexercise WBC session in the evening decreased biomarkers of oxidative stress in elite kayakers.

Pournot et al. (76) demonstrated that a single 3-min WBC session at −110°C immediately following exercise reduced biomarkers of inflammation including select interleukins and c-reactive protein compared with passive exercise.

In 2011, Hausswirth et al. (42) compared postexercise WBC with far-infrared (FIR) and passive recovery. None of the three recovery methods had any impact on creatine kinase levels at 1, 24, or 48 h after exercise. Maximum voluntary contraction was assessed using a knee extensor ergometer and was noted to be recovered to baseline levels 1 h after exercise in the WBC group versus after 24 h in the FIR group and not within 48 h for the passive group. Pain and tiredness levels also were reduced in the WBC group at 1 h after exercise. The FIR group experienced only decreased pain after 48 h. Neither pain nor tiredness was reduced within the 48-h study period in the passive group (42).

In 2014, Ferreira-Junior et al. (34) published results of partial body cyrotherapy (PBC) intervention immediately following muscle-damaging exercise and demonstrated improvements in peak torque measurements at 72 and 96 h compared with placebo. The PBC group also experienced complete muscle soreness recovery at 72 h compared with the placebo group, which was not recovered within the 96-h study period (34). Also in 2014, Ferreira-Junior et al. (35) published that a single session of PBC improves eccentric muscle strength recovery at 40 min after exercise.

In summary, other than the strongly beneficial effect of cold water immersion to maintain low core temperature and improve performance during repeated bouts of endurance exercise in the heat, there is generally limited low-quality evidence to support cold water immersion as an effective recovery aide. However, the small improvements in DOMS and some types of athletic performance may be important to some athletes under certain circumstances. Athletes, coaches, and sports medicine professionals should carefully review the available literature before employing cold as a recovery aid. Depending on the athletic task, training environment, and recovery goals, cold water immersion may or may not be beneficial. Several studies have shown that preexercise treatment with WBC reduces biomarkers of oxidative stress and lipid peroxidation products, which may lead to decreased muscle damage. These studies show that one to three sessions of WBC per day is beneficial and more treatments may be more beneficial. Some markers of inflammation have been shown to be reduced following treatment with WBC. Creatine kinase levels have not been consistently reduced following treatment with WBC. Strength and perceived tiredness have been shown to recover more quickly with WBC treatment. PBC does provide modest improvements in recovery but appears to be inferior to WBC.

Cryotherapy and cold water immersion should only be used in a controlled and supervised environment. There is a theoretic risk of hypothermia and cold-induced arrhythmia should the athlete stay exposed to the cold environment for too long. Direct application of ice or cold packs can cause frostbite and also should be applied for no longer than necessary and monitored throughout the treatment.

Heat

While there is some low-quality evidence to support the benefits of cold as a recovery aid, studies designed to assess the impact of various types of heat treatment on recovery have provided only limited insight and yielded conflicting results. Heat has been proposed to be a useful treatment for decreasing muscle soreness by increasing blood flow to targeted muscles, improving muscular oxygenation, and helping flush exercise-related waste products away from the recovering muscles (16). In addition, there is a theoretic benefit of heat on modulating postexercise protein synthesis (58,68).

A number of heat-related strategies, primarily involving sauna/spa treatments or hot water baths, have been utilized in an effort to enhance the recovery phase after training and competition (18,24,36,46,50,59,94). However, most of these studies have actually included a blend of heat and cold treatments (e.g., contrast and spa therapies), and there is no substantive evidence to suggest that application of heat alone is a beneficial recovery modality.

For instance, heat treatment in the form of ultrasound (16) or as a topical application (54) to muscles after an exercise bout failed to prevent DOMS in subjects who had performed eccentric contraction tasks. In addition, in a recent in-depth review of the potential use of different water immersion methods to aid in exercise recovery, the authors concluded that hot water immersion is not an effective aid in performance recovery (93).

FIR therapy, which has been used to relieve pain in patients with muscular disorders (62), has more recently been evaluated as a recovery treatment (42). However, when compared with cryotherapy interventions, subjects who had performed a simulated trail running race and subsequently received FIR treatment showed minimal improvement in their recovery profile.

An additional consideration in this area is the potential impact of heat on cellular and molecular processes. There is clear evidence that whole body heat stress can stimulate stress proteins and cell signaling cascades and impact cellular oxidative status, and these processes could have a range of effects, both beneficial and deleterious, on muscle recovery from exercise (58,68,89).

In contrast to cold treatments, which can reduce blood flow, inflammation, and swelling to injured muscles (2,14,43,95), there are some potential adverse consequences associated with the utilization of heat treatments during the recovery phase that would suggest that such an approach is contraindicated. For instance, application of heat immediately after a workout (or injury) can have the deleterious effect of increasing blood flow to a site and enhancing swelling or inflammation (24). While there is no strong evidence to support the benefits of heat on recovery from an acute exercise bout, it should be noted that different forms of heat treatments are routinely used for acute treatment of stiffness and soreness.

Conclusions

The reviewed recovery aids may each be beneficial to certain athletes in certain situations. Compression garments may help athletes recover from training sessions by decreasing DOMS and improving subsequent performance on tasks of strength and endurance. Massage has promising data from an animal model, and several surrogate markers of recovery are improved with postexercise massage; however, it has limited evidence as a recovery aid in humans. It may delay DOMS but also may worsen muscular strength in the hours after the treatment. Most athletes need not employ any particular caloric replacement strategy to maximize recovery. But for athletes who have short (<24 h) intervals between bouts of exercise or competition, it is beneficial to eat earlier following exercise and eat foods with a higher glycemic index. Cold water immersion has a large benefit for maintaining performance during repeated bouts of endurance exercise in the heat and has a small benefit on DOMS and recovery of sprint speed. It does not provide any benefit on other markers of recovery or performance. Whole body cooling attenuates markers of oxidative stress when applied prior to exercise and may cause decreased pain and tiredness soon after exercise. Heat is generally not an effective recovery method.

Each of these recovery techniques is difficult to study in a systematic manner. Future studies should aim to control for timing, dose, and intensity of the intervention and attempt to control for context and meaning effects when possible. Most importantly, we as sports medicine professionals should be honest with our athletes when discussing recovery modalities. Our evidence base is quite limited, and techniques with long histories that have become standard practice on fields, courts, gymnasiums, and training rooms may not always be beneficial.

The authors declare no conflicts of interest and do not have any financial disclosures.